Droopy Eye and Eyebrows After Botox

I had Botox done before and always being happy with the outcome result. This time, I came to Houston and got Botox. The following morning, I got a droopy eye. I went to a second doctor who promised he can fix the problem by injeccting 15 units more. Now, I look even worse and uneven, with a droopy eyebrow aside from the droopy eye. I'm using Alphagan P, but now I'm really concerned. How long will this last?

Droopy eyelid and droopy brow are two seperate issues

March 30th, 2009

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A droopy eyelid results from unwanted relaxation of the levator muscle. In your situation, the droopiness happened rather early and some swelling (i.e. adding weight to the lids) may have been involved, too.

The brow droop results from over-relaxation of the frontalis muscle. this muslce creates the horizontal forehead creases. It sounds like the second doctor tried to counteract the droopy brow by injecting Botox into the orbicularis muscle. Sometimes, this works, but not always.

Longevity of these side effects depend on the amount of Botox present in these muscles. It may be anything between 4 and 16 weeks. There is probably not much to do at this point aside from watchful waiting. In addition, talk to your doctors.

"Droopy Eye and Eyebrows" After Botox

The good news is that none of these effects are permanent and you likely WILL improve.

With that said, lets discuss both your symptoms -- the droopy eye-LID and eye-BROW...

(1) A drooping eye-BROW may happen when the brow-elevating muscle in the forehead, the Frontalis, receives too high a dose of Botox, or alternatively, if the Botox is sub-optimally placed too low in the forehead. Of note, it may also happen if you have a low set eyebrow to begin with, in which case any Botox to the Frontalis increases the likelihood of a brow droop. A droopy eyebrow from Botox can sometimes be improved with Botox injected into the outside part of the eye (the lateral aspect of the orbicularis oculi muscle) to generate a bit of a brow lift in that area -- by injecting more Botox and paralyzing the orbicularis muscle that normally acts to depress the brow in that area, you may get a slight compensatory brow lift... If your injecting physician already injected this area, I would receive no further injections and wait for the Botox to wear off...

(2) A droopy eye-LID may occur if the Botox is injected too close to your eyelid-elevating muscle, the levator palpebra superioris. In such a scenario, the Botox will diffuse inadvertently onto the levator muscle and cause an eyelid droop. You may have an increased risk of eye-LID drooping if you have a weakened upper eyelid muscle for neurological reasons, or a deeply set eye-BROW that would be more prone to drooping (as discussed above) and result in skin gathering over the eyelid making the eyelid appear like it was drooping. A droopy eye-LID due to Botox can be treated with Apraclonidine eye-drops which can provide a small (2mm) improvement -- Apraclonidine 0.5, 1-2 drops, 3 times per day. Make sure you put in one drop at a time, tilt your head back, and close your eyes to make sure none of the eye-drop leaks out. Be sure your prescribing physician discusses all the potential side-effects of the drops, such as "adrenaline-like" symptoms like anxiety or heart pounding; you may also experience eye irritation, eye dryness, and eye pain, amongst other symptoms. If these symptoms occur, you will likely need to take some lubricating eye drops, lower the dose, switch the eye-drops, or stop the drops altogether...

My recommendations are to seek the services of an experienced physician injector.

I think the key with Botox lies in truly understanding the anatomy of the injected area, and more importantly the variability in the anatomy between patients -- for brows, the forehead, and anywhere else you plan on receiving a Botox injection. This includes having a firm understanding of the origin, insertion, and action of each muscle that will be injected, the thickness of each muscle targeted, and the patient variability therein. As an aesthetic-trained plastic surgeon, I am intrinsically biased since I operate in the area for browlifts and facelifts, and have a unique perspective to the muscle anatomy since I commonly dissect under the skin and see the actual muscles themselves. For me, this helps guide where to inject and where not to. However, with that said, I know many Dermatologists who know the anatomy well despite not operating in that area, and get great results.

Botox Pictures

Droopy eye and eyebrow

March 30th, 2009

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This is an unfortunate incident, but your droopy eye and brow should not be permanent because the effects of Botox are not permanent. The droopy eyelid is uncommon but can occur particularly when the injection site on the forehead is close to the eyebrow. You should see gradual improvement over the next 1-2 months. You might want to inform both of your doctors what happened to help prevent this complication from occurring in their future patients.

Upper eyelid "ptosis"

Unfortunately, you have been given Botox too close to the eye. this has resulted in weakness of the muscle that helps open the eyelid (AKA the Levator Muscle).

The reason Alphagan helps is because it works on another muscle (AKA Muller's Muscle) keep the eyelid open.

As you know Botox generally lasts about 3-4 months. Fortunately the effect of Botox on the Levator Muscle is shorter than it is in other areas. You should begin to see improvement within a couple of months.

As evidenced by your previous experience with Botox, I can assure you that Botox is a a safe product that can achieve excellent results in the hands of a properly trained plastic surgeon.

The longevity of the droop depends on whether you respond to the Alphagan.the

March 30th, 2009

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Dear Ana

I just complete a study of patients referred for management after developing a droopy upper eyelid after cosmetic BOTOX. This is a rare situation but that fact I know will be of little comfort.

The dose of BOTOX you got to treat the orbicularis oculi after developing the droop is much higher than is usually advised. The orbicularis is the muscle that helps close the eye. If it is weakened too much you actually will have trouble closing the eye and this can lead to severe drying of the corneal surface which believe it or not is much more serious a problem then difficulty opening the eye. At least when you can't open the eye, it is protected. When the eye does not close properly, the corneal drying can threaten vision. The usual dose of BOTOX to adjust the heavy eyelid is less than 4 units of BOTOX.

The upshot of my study is that if you respond to the Alphagan, then the longevity of the ptosis is likely to be 4 to 6 weeks. If the eyelid is not improved by the drops, the ptosis is likely to take 3 to 6 months or longer to resolve.

I would recommend that you get assessed by a fellowship trained Oculoplastic surgeon in your area to evaluate the eye and monitor your progress to having resolution of the issue. The American Society for Ophthalmic Plastic and Reconstructive Surgery maintains a directory of members on their website: ASOPRS.org.

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